Study population

The total study sample was ten participants, of which seven were male, and the average age was 40.60 years (SD = 12.40, Mdn = 43.50, range = 21–57, IQR = 20.75). Six participants were single and four had a university degree or a higher educational level, five were unemployed at the time of the beginning of the study. Eight participants reported having at least one other diagnosed psychological disorder and five reported living in a small town or village (≤ 20.000 inhabitants). All sociodemographic characteristics are presented in Table 2. All ten participants reported to wanting to stay abstinent in the coming six months, of which five were confident and four somewhat confident to be able to reach this goal, while one person reported not being confident at all.

Table 2 Sociodemographic Characteristics of Participants at Time of Screening7-day point abstinence

Eight participants reported a 7-day point abstinence at the time of the interview, while two (P01, P09) reported to having consumed alcoholic beverages in the past seven days. The participants reported on average 117.20 days of abstinence in the abstinence tracker (SD = 56.05, Mdn = 107.50, range = 32–205, IQR = 78.25). These data included an initial input for days of abstinence between beginning of inpatient treatment and first app use.

Abstinence motivation and return to alcohol useReturn to alcohol use

The participants reported on average 6.10 days of alcohol use in the abstinence tracker (SD = 4.61, Mdn = 6, range = 1–15, IQR = 6.75) over a period of six months. All interviewees were asked whether they had returned to alcohol use during the study period and whether they had reported this in the app. Although participants had been selected for this study based on recorded alcohol use in the app, two participants (P02, P10) stated to have been abstinent during the complete study period. Being asked about it, they said that they would have reported any alcohol use in the app. One participant (P07) stated to have discontinued use after the coaching period. All others reported to having used alcohol at least once and having reported this in the app. Some individuals explained their situations of the return to alcohol use, one participant (P01) stated she had returned to alcohol use due to a feeling of having been hurt by others, another (P06) stated the death of her brother had been a trigger: “It was just a bad farewell the last four weeks and yes, bad. And then, yes, it was actually logical for me that something like that would happen”. Others mentioned stressful situations and anger (P07), loss of contact with friends, a break-up, problems at work, and the loss of someone to talk to after the end of the withdrawal program (P09).

Five participants (P02, P04, P05, P06, P08) reported they had received support from family and friends after the return to alcohol use, three participants had received professional help from a psychologist (P06), additional counselors (P05), and a self-help group (P03). Three participants stated not having received any help, one participant felt this was due to the COVID-19-pandemic: “[…] That was the time when everything really shut down and I had an appointment, I had already called an addiction counseling center and they said they would try me somehow, but this Corona broke so much”. One person (P01) said she had wanted to be left alone after returning to alcohol use.

Abstinence motivation

Based on the answers provided, abstinence motivation was categorized in approach and avoidance goals. One major theme in the avoidance goals was fear of negative consequences. One person (P01) disclosed she had difficulty believing that she could be struggling with AUD, indicating difficulty integrating her current situation into her constructed self-image and explaining abstinence motivation. Another person (P03) expressed that she wanted to avoid social judgment by others in her self-help group as well as the study team behind the app: “I didn’t want to have to admit to my addiction group that I had been drinking, and in there I also thought, uh, otherwise I would have to say yes, and I didn’t want to do that, so sometimes I rather didn’t drink anything because I didn’t want to admit that […] So I never knew whether someone would look at what I typed in there or not or something. And I always imagined that I would type in crap like that, maybe I didn’t disappoint them now because they don’t know me personally, but it was very uncomfortable for me to type in no”. She was also afraid of losing her job and driver’s license. One person (P06) reported she did not want to suffer the consequences, in the short term a hangover and in the long term, weight gain.

Considering approach goals, two individuals (P10, P09) stated they wished to regain quality of life and be present in the moment: “Yes, the recovery of my quality of life, but I really only understood that through withdrawal, then so after 3 weeks, when I then sat on a park bench, and again perceived birds chirping again, and it just got all better somehow” (P09). The person also stated to enjoy receiving positive feedback on his appearance after a period of abstinence which additionally motivated him. There were also social aspects for abstinence motivation. One person (P07) stated he wanted to take part in social life again and three others (P09, P03, P02) mentioned their biggest motivation was their family, friends and partners. Two individuals had responsibilities towards others (P01, P06). Four individuals (P04, P05, P07, P10) reported they wanted to feel proud of themselves and their achievements and have a “clear head”. One person (P08) was motivated by wanting to maintain physical health and fitness and two others (P01, P02) felt they needed to stop drinking due to existing comorbid diseases.

Motivation after return to alcohol use

Considering change in motivation after the return to alcohol use, the following categories were determined: (1) decrease of motivation, (2) increase of motivation, (3) no change in motivation. Seven of the 10 participants reported an increase in motivation. The participants had the following explanations for their increase in motivation, two individuals (P03, P09) reported the way the app “reacted” had an impact: “[…] and also the app, it didn’t wag its finger nastily, but you’ll manage it again tomorrow and so on. That was a motivating reaction.“; “I also thought it was good that when negative pressure was applied, that was about 5 times in the half year, that it didn’t say, oh my God, get help, but it was motivating somehow, keep going, keep at it”. One participant (P03) said the non-judgmental support of her support group after opening up about the return to alcohol use had a positive effect. For four participants (P01, P02, P05, P07) realizing the negative effects of their drinking behavior increased their desire to regain control over their life and decisions. Two individuals (P07, P08) began to seek additional professional treatment. Three out of ten participants stated that they had an initial decrease of motivation after the return to alcohol use. They explained that they became depressed after the return to alcohol use and reported that, at first, abstinence didn’t matter anymore.

App useQuantitative app use

App use defined as days of active app use varied strongly between individuals, with a range of 31 to 181 (M = 109.70, SD = 52.42, Mdn = 103.00, IQR = 76.75). While there was no large difference in the mean number of days of active app use before (M = 51.00, SD = 36.76, Mdn = 41.50, range = 2–97, IQR = 60.00) and after (M = 58.70, SD = 25.96, Mdn = 58.50, range = 24–96, IQR = 44.25) the return to alcohol use, variance was high and a closer look at the individual app use data reveals that participants with less use days before the return to alcohol use seemed to have less use days in total. Nevertheless, both participants with an early return to alcohol use as well as participants with a later return to alcohol use used the app for several weeks after the return to alcohol use. Participants completed 86.80 tasks on average but the high range from 16 to 222 (SD = 59.00, Mdn = 63.00, IQR = 65.00) shows that participants differed greatly in their use behavior. The mean number of resolved tasks decreased from 55.30 before the return to alcohol use (SD = 36.03, Mdn = 49.50, range = 13–125, IQR = 39.75) to 31.50 after (SD = 53.06, Mdn = 13.00, range = 0-175, IQR = 35.00). Especially those participants with a higher number of use days before the return to alcohol use seemed to severely reduce their completion of tasks, with three of them resolving zero tasks after the return to alcohol use (P03, P04 and P09) although they still had a high number of active use days following their return to alcohol use. The number of times the emergency area was accessed ranged from 2 to 25 in total, with a mean of 10.10 (SD = 9.12, Mdn = 5.00, IQR = 13.25). There was no clear pattern of change in the number of access of the emergency area before and after the return to alcohol use. Participants accessed the motivation area 24 times on average, but again, the high range from 6 to 82 times of access reveals a large difference in the use behavior (SD = 22.34, Mdn = 16.50, IQR = 11.25). The app use data indicate a decrease in the number of access of the motivation area after the return to alcohol use, with a mean of 20.50 before (SD = 22.07, Mdn = 14.50, range = 2–79, IQR = 6.00) and a mean of 3.50 after (SD = 3.37, Mdn = 2.50, range = 0–11, IQR = 4.50) the return to alcohol use. Table 3 displays detailed information on app use of all ten participants.

Subjective app use behavior in general

Eight participants reported using the app on a daily basis, mainly to complete the abstinence tracker. The other two (P05, P07) reported having used the app once or twice a week. Some (P01, P02, P09) stated that their use frequency decreased over the study period of six months. Seven participants stated their average use was about ten minutes a session while three (P04, P05, P09) reported to having used the app for about one hour a session. When asked in what situations and when the interviewees used the app, five (P01, P02, P04, P05, P06) reported to having used the app when they felt they had spare time and one individual (P03) was using it every evening. One person (P08) used the app when he was feeling especially good while two others (P01, P08) used it when they felt they were struggling. Two participants (P01, P04) stated they used the app when feeling craving and one participant (P10) described use when passing through high risk situations: “[…] that was when I was out and about, for example when I passed a beer garden, or a restaurant or so”. Two (P08, P01) stated they used the app in situations of alcohol use. Prompted on further situations individuals used the app, one (P09) stated in situations of boredom, two (P03, P08) wanted to keep engagement in the abstinence tracker high and one person (P07) said that he used it before preparing for the coaching which was part of the intervention. He also stated to have discontinued app use after the coaching was finished.

Four individuals clearly stated that the end of the coaching sessions did not affect their use behavior. In response to whether the reminder push notifications increased use, six participants answered affirmatively, two (P09, P06) stated not having received the reminders as their app use was already on a daily basis and one (P02) did not receive reminders due to technical issues. One person (P07) stated the reminders did not motivate app use.

Subjective app use behavior after return to alcohol use

Seven participants (P01, P02, P03, P04, P05, P06, P08) stated their app use behavior had not changed after the return to alcohol use. Two (P02, P09) had reduced their use frequency, one person (P02) because he attended a rehabilitation program. Upon further exploration, five participants used specific content in the app after the return to alcohol use, two (P02, P03) reported frequenting the motivation section, one (P03) chose to do the “Swipe” exercises: “I even did one of those exercises with pushing away and stuff, I thought who knows even if it doesn’t seem to make sense to my mind. But for the psyche it might be good anyway, and I just did that, just, again without much expectation, but I did it and thought, who knows, might be helpful”. Two participants (P08, P09) mentioned having used the emergency plan and one person (P05) engaged in daily practice to be mindful of his current situation and heighten awareness for risky situations.

Helpful and hindering factors of the intervention regarding abstinence motivationHelpful and hindering factors of the app regarding abstinence motivation

Statements about the app could be divided into (1) positive and (2) negative evaluations, and (3) general suggestions for adaptions. All participants mentioned at least one positive aspect. One participant (P09) felt supported by the daily notion for reflection and confrontation with their problems. Another participant stated something similar and added that the app could not be a total treatment substitute “[…] using the app alone is like medication, it can only be supportive, but can’t replace everything” (P08). Two individuals (P04, P05) found the diversity of content appealing and one person (P05) liked the interactive approach. “The interactive approach has definitely brought me a lot, so that when you read something, you tend to digress or forget that you’ve read it, but when you record it as an audio file or write it down and photograph it or whatever, then the learning material simply sticks better and the content simply sticks better”. Three individuals (P01, P09, P10) stated that they found the section for personal motivation particularly helpful, in which they were able to upload a personal photo. One participant (P09) exclaimed that he liked that there were daily exercises he could do and highlighted the emergency plan.

The daily abstinence tracker was rated positively by all interviewees. For some it was motivating to see how many days of abstinence they had already achieved, “I find that very helpful, I now also have that in an app that counts that, […] because that keeps the success in front of your eyes” (P02), and the daily reminder helped: “It helped me to then be reminded every day and I had to answer the couple of questions and yeah, I was looking forward to it part of the time that I had to do it or be reminded of it” (P10).

Negative evaluations of the app included that one participant (P01) was displeased that abstinence days could not be reported retrospectively but had to be reported daily. One participant (P05) criticized the general structure of the app: “Because there is no logical sequence of questions and topics, but because you have to find your own way around and then the app suggests, for example, some other module and you say, no, I don’t really want that now and I would have preferred a tighter guidance in quotation marks or a more structured guidance […]”. Another comment was dissatisfaction with the Swipe exercise about feeling it was too basic: “I kind of felt like I was in kindergarten there, I mean when I see pictures there of someone drinking alcohol and I’m supposed to press no there, I feel like I’m taking an idiot test 20 years ago, so that wasn’t that thrilling.” Further comments were that one person (P07) would have needed more pressure to engage in the program and another (P06) stated she believed her craving would still be strong even if she used the app in personal risk situations. She also felt the app was overloaded with content thus not being able to complete all modules.

Some participants also made suggestions for improvements of the app, for example to have all days of abstinence displayed per month for an overview (P01), one participant (P09) felt he would like more support after alcohol use was reported and suggested the implementation of a peer chat group to communicate with others: “Especially in these times when you’re not allowed to meet, when you’re there, this exchange is very important, because I’m still in contact with former drinkers who have all made it and so on, the solidarity is insane.”

Helpful and hindering factors of the coaching regarding abstinence motivation

Four individuals (P03, P06, P08, P10) commented positively on the coaching while two of them (P06, P08) returned to alcohol use during the first weeks, when telecoaching was still ongoing. One person (P06) recalled the support of the coaching after her return to alcohol use: “She also talked to me on the phone in the meantime, where I wrote that it had happened that I had been drinking. And I wrote that to her as an email and then she called me, and I thought that was totally super.” One person (P01) who also returned to alcohol use during coaching period felt the coaching was not helpful: “Yes, […] I got along well with the lady, but for me it’s just hard when they do not know me. To me so many things are simple, and then I have to tell her something, and then tell her something else, so that she understands the context, why and back and forth”.